Central vein catheterization technique
Central venous catheter( CIC) is not required for patients in a wakeful state with stable circulation and patients who do not receive solutions of high osmolarity. Before placing such a catheter, all possible complications and risks must be weighed. In this article, we will look at how the central vein catheter is performed.
Selecting the location of the
When choosing the location of the catheter( puncture), first of all, the experience of the health worker is taken into account. Sometimes the type of surgery, the nature of the lesion and the anatomical features are taken into account. In particular, for male patients, a catheter is placed in the subclavian vein( since they have a beard growing).If the patient has high intracranial pressure, the catheter should not be placed in the jugular vein, as this may make it difficult to drain blood.
Alternative sites for puncture are axillary, medial and lateral subcutaneous veins of the hands, in which the installation of a central catheter is also possible. A special category includes PICC catheters. They are installed in the vein of the shoulder under the control of ultrasound and may not change for several months, representing, in fact, an alternative version of the port. Complications of a specific type are thrombosis and thrombophlebitis.
Central vein catheterization is performed according to the following indications:
- Necessity of administering hyperosmolar solutions to the patient( more than 600 mosm / l).
- Control of hemodynamics - measurement of central venous pressure( CVP), hemodynamic monitoring of PICCO.Only the measurement of the CVP is not an indication for the installation of the catheter, since measurements do not give an accurate result.
- Measurement of blood saturation level with carbon dioxide( in individual cases).
- The use of catecholamines and other substances that irritate the veins.
- Prolonged, more than 10 days, infusion treatment.
- Venous dialysis or venous hemofiltration.
- Purpose of infusion therapy for poor peripheral veins.
Contraindications to catheter installation are:
- Infection lesion in the puncture area.
- Vein thrombosis, in which a catheter is planned.
- Disrupted coagulation( condition after system failure, anticoagulation).In this case, a catheter can be inserted into the peripheral veins on the arms or thigh.
Site selection and precautions
Some rules must be observed before catheterization of the central vein:
- Precautions: Use of sterile gloves, masks, a cap, sterile gown and napkins, special attention should be paid to skin disinfection.
- Patient posture: the best option is to head down, as this facilitates the insertion of a catheter into the jugular and subclavian veins. This also reduces the risk of pulmonary embolism. However, it should be borne in mind that such a position of the body can provoke an increase in intracranial pressure. The set for central venous catheterization according to Seldinger will be discussed below.
Selecting a location for puncture is an important step in the procedure and involves the following limitations:
- An alternative to the method of orientation by anatomical features is the puncture of the jugular and subclavian veins under the 1/3-control. This method visualizes the anatomical features and reduces the risk of complications such as an incorrect catheter position or incorrect puncture( with hematoma).
- Local anesthesia. If the patient is conscious, then an easy anesthetic is administered before the procedure, in some cases, a mild sedation with a shot of midazolam.
- Venous puncture. If it is an external, anterior or internal jugular vein, the puncture is performed by a syringe filled with half saline. In this case, the CEC is established by the Seldinger method. If a subclavian vein is to be inserted, the j-shaped wire conductor is directed downward. The catheter is located 3-4 centimeters under the clavicle to the right of the parasternal line. A constant monitoring of the electrocardiogram parameters is necessary, since too deep insertion of the catheter can disrupt the heart rhythm. This will help set the pediatric for catheterization of the central veins.
- Aspiration test. The syringe is removed after placement of the catheter to understand whether arterial or venous blood comes from the puncture site. If there are doubts, then the blood is taken for analysis. If aspiration occurs freely, then the established catheter can be used for infusion therapy. It is necessary to check the correctness of the installed catheter with the help of an X-ray and only then fix it.
- Monitoring of the patient's condition. Immediately after the placement of the catheter, the patient needs intensive monitoring to determine in a timely manner the complications that may occur with pneumothorax.
- CEC.Each installed catheter should be marked in a special schedule with the date, place of installation and type of catheter. In the case of emergency catheter insertion without observing aseptic conditions, it should be removed as soon as possible and sent for analysis. The set for central venous catheterization according to Seldinger is the most popular.
The system must be disconnected and manipulated. The kinks and unsanitary conditions of the catheter are unacceptable. The system is fixed in such a way that there are no displacements in the puncture area. The development of complications and the risk of their occurrence should be checked daily. The best option is to apply a transparent bandage to the catheter insertion site. Urgent removal of the catheter is subject to systemic or local infection when the central vein is catheterized.
To avoid an urgent removal of the catheter, strict adherence to hygienic norms and asepsis must be observed when installing it. If the CEC was installed at the scene of an accident, it is removed after the patient is taken to the hospital. It is necessary to exclude any unnecessary manipulations with the catheter and follow the rules of asepsis while taking blood and injections. Disconnection of the catheter from the infusion system requires disinfection of the nozzle with a special solution. It is necessary to use sterile dressings and disposable stoppers for a three-way valve, minimize the number of tees and joints, and strictly monitor the protein, leukocyte and fibrinogen levels in the blood to avoid infection.
Following all these rules, you can not change the catheter frequently. After removing the CIC, the syringe is sent for a special study, even if there are no symptoms of infection.
The length of the needle stay for central venous catheterization is not regulated, it depends on the patient's exposure to infections and the body's response to the introduction of the CIC.If the catheter is installed in the peripheral vein, the replacement is necessary every 2-3 days. In the case of a central vein, the catheter is removed at the first symptoms of sepsis or fever. A syringe, removed under sterile conditions, is sent to a microbiological study. If the need to replace the CIC occurs in the first 48 hours, and at the puncture point there is no irritation and signs of infection, a new catheter is placed according to Seldinger's method. Observing all the asepsis prescriptions, the catheter is delayed by several centimeters so that it remains with the syringe in the vessel, and only after that the syringe is removed. After the gloves are replaced, a conductor is inserted into the lumen and the catheter is removed. Next, a new catheter is inserted and fixed.
Possible complications of
After the procedure, the following complications are possible:
- Hematoma, hemomediatinum, hemothorax.
- Arterial puncture with risk of vascular integrity. Hematomas and bleeding, false aneurysms, strokes, arteriovenous fistulas and Horner's syndrome.
- Pulmonary embolism.
- Puncture of the vessels of lymph with chylomediastinum and chylothorax.
- Incorrect position of catheter in vein. Infuzorothorax, finding a catheter in the pleural cavity or too deep in the ventricle, or the atrium on the right side, or the wrong direction of the CCV.
- Damage of the brachial or cervical plexus, diaphragmatic or vagus nerves, stellate node.
- Sepsis and infection of the catheter.
- Thrombosis of the vein.
- Cardiac rhythm disturbance during catheter advancement for central venous catheterization according to Seldinger.
Installing the CAF
There are three main areas for installing the central venous catheter:
- Subclavian vein. Jugular inner vein.
- Femoral vein.
A qualified specialist should be able to put a catheter in at least two of these veins. When central venous catheterization is particularly important ultrasonic control. This will help localize the vein and determine the structures associated with it. Therefore it is important to be able to use an ultrasound machine if possible.
Sterility of the kit for catheterization of the central vein is of paramount importance, since it is necessary to minimize the risk of infection. The skin needs to be treated with special antiseptics, place the injection with sterile napkins. Sterile gowns and gloves are strictly required.
The patient's head goes down, which allows filling the central veins, increasing their volume. This position facilitates the process of catheterization, minimizes the risk of pulmonary embolism during the procedure itself.
The internal jugular vein is most often used to install a central venous catheter. This type of access reduces the risk of pneumothorax( compared to subclavian catheterization).In addition, in case of bleeding, it is stopped by pinching the vein by compression hemostasis. However, this type of catheter is inconvenient for the patient, it can displace the wires of the temporary pacemaker.
Action on the
protocol The protocol for central venous catheterization involves the following actions:
- The most optimal is the use for the catheterization of the needle according to Seldinger( introduction on the conductor).Catheters, similar to peripheral, are more difficult to establish.
- Before administration, it is necessary to anesthetize the skin and cellulose with lidocaine( 1-2% solution).
- The needle is put on a syringe with a solution of sodium chloride.
- The conductor is located in a sterile place for easy access.
- The skin is incision with a small scalpel. This is done to facilitate the process of inserting the cannula.
- Next, you need to move the needle forward, pulling the piston to maintain negative pressure.
- If you can not get into the vein, you need to slowly tighten the needle, continuing to maintain a negative pressure in the syringe. There are cases of a vein piercing through. In this case, pulling up the needle helps.
- If the attempt to install the catheter is unsuccessful, the needle is washed to remove the particles closing the lumen. Further, the location of veins is again evaluated and a new tactic of insertion of the catheter is determined.
- As soon as the needle enters the vein and blood enters the syringe, you need to push the needle a little backward or forward so that the blood can flow smoothly.
- With one hand supporting the needle, remove the syringe.
- Then a flexible wire conductor is introduced. It passes into the needle pavilion with the minimum possible resistance. You can make this procedure a little easier by changing the angle of the bevel.
- If the resistance when moving the conductor is strong enough, it is necessary to check the position of the needle by conducting blood aspiration.
- Once the large half of the conductor has been inserted into the vein, the needle must be removed and the catheter with the dilator placed on the conductor.
- The introducer can not be moved forward until a small section of the conductor begins to protrude beyond the distal end of the expander and will not be firmly fixed.
- If there is resistance to the introduction of the CEC, you can enlarge the cut. If resistance occurs in the deep layers, you can first introduce a small diameter dilator to open the passage.
- After complete installation of the catheter, the expander is removed, and the CIC is secured with a transparent dressing and ligature.
- In conclusion, an X-ray examination is performed to monitor the position of the catheter. In case of installation without complications, the catheter can be used immediately without additional control.
Access to the subclavian vein
The insertion of a catheter into a subclavian vein is used when there is no access to the patient's neck. This is possible when the heart is stopped. The catheter placed in this place is located on the front of the thorax, it is convenient to work with, it does not cause inconvenience to the patient. Disadvantages of this type of access is a high risk of pneumothorax and the lack of the ability to squeeze the vessel if it is damaged. If the catheter was not installed on one side, you can not immediately try to enter it on the other, as this dramatically increases the risk of developing pneumothorax.
The installation of the catheter involves the following:
- There is a point on the top of the rounded edge of the clavicle between one-third of the medial and two-thirds of the lateral.
- The location of the insertion is located 2 centimeters below this point.
- Next, anesthesia is administered, with an anesthetic being both a puncture site and a clavicle area around the original point.
- A needle for catheterization is administered in the same way as anesthesia.
- As soon as the end of the needle is under the collarbone, you need to turn it to the bottom point of the jugular notch of the sternum.
Access through the artery of the thigh is especially often used in emergency cases, as it helps to enter a large vein for further manipulation. In addition, with this form of access, it is easy to stop bleeding by squeezing the vein. This access allows you to put a temporary pacemaker. The main complication of this type of catheterization is the high risk of infection and the required immobility of the patient.
How is the catheter installed?
The catheter is installed as follows:
- The patient is in a horizontal position. The leg unfolds and is diverted to the side.
- The inguinal region is shaved, the skin is treated with an antiseptic and covered with sterile napkins.
- The femoral artery is palpated in the area of the fold at the base of the foot.
- Anesthesia of the catheter insertion area is made.
- The needle is inserted at an angle of 30-45 degrees.
- Vienna is located usually at a depth of about 4 cm.
Central vein catheterization is a complex and dangerous medical manipulation. It should be conducted only by an experienced and qualified specialist, since an error in this case can cost the patient life and health.
What is included in the set for central veins catheterization two-channel?
As part of a sterile( disposable) installation kit, a port camera, a port catheter, a thin-walled needle, a 10 cm3 syringe, two lock locks, a conductor with a soft J-tip in the unwinding device, two Huber needles without a catheter, a vein lift, one Hubert needlewith fixing wings and attached catheter, buz-dilator, tunneler, splittable introducer.
Central vein catheterization set
The kit is designed for catheterization of the superior vena cava by Seldinger's method. Long-term administration of medicines, parenteral nutrition, invasive monitoring of blood pressure may be required.
Known for a set of catheterization of the central veins "Zertofix."
As part of the kit you can see:
- Polyurethane radiopaque catheter with extension cords equipped with a clamp.
- Igloo Seldinger( introducer).
- Conductor straight nylon.
- Dilator( extender).
- Additional fixation for fixing to the patient's skin.
- Plug with injection membrane.
- Mobile clamp.
The set for catheterization of the central veins "Zertofix" is used most often.